Coeliac disease: the great imitator

To the Editor: Duggan’s recent article on coeliac disease1 is a timely reminder of the complex manifestations of this common but under-recognised condition.

I write as a patient diagnosed with coeliac disease at the age of 80. Throughout my life I have had aphthous ulcers, all sorts of abdominal pains, diarrhoea and constipation, dermatitis herpetiformis and profound fatigue. The extraordinary fact is that — apart from missing the diagnosis myself — I come from a medical family and have worked in a variety of medical environments both in Australia and overseas. My physique and weight were obviously substandard. Over the years, I consulted many physicians, surgeons and general practitioners. They diagnosed hiatus hernia (a fundoplication was done), gallstones (a cholecystectomy was done), irritable bowel syndrome, and, of course, psychoneurosis.

I consulted three gastroenterologists, two of whom performed gastroscopy but did not take a duodenal biopsy. As I entered the rooms of a fourth, the secretary said, “I know your diagnosis” — and she was right. A duodenal biopsy showed flattening of the villi.

Since going on a gluten-free diet, I have gained weight, the pains have gone, and the rash and ulcers have not recurred. A second biopsy, performed 6 months later, revealed restoration of the intestinal surface to its normal appearance.

Not only is it a disease of malabsorption, but also one of malnutrition. This accounts for its widespread manifestations. Brain and nerve cells require adequate nutrition, just as any other cells of the body. I found, at times, difficulty in focusing attention, comprehension and cognitive processing. The spoken and printed word were meaningless on occasions. The fatigue was sometimes overwhelming.

Galen first described the illness in 2 ad, but it took Dicke, a Dutch paediatrician, to trace the culprit to gluten in 1950. He found that children with coeliac disease fared better than usual when deprived of wheat during the Occupation. Other grains subsequently found to contain gluten were barley, rye and oats.

Duggan points out that coeliac disease, like syphilis, is a great imitator. Not only is it a condition that can vary widely in its ramifications, it is the only illness treated by lifelong diet restriction. A pathologist colleague, diagnosed at a late age like myself, shares with me the fear of developing lymphoma — a not uncommon sequel to untreated coeliac disease.